Why Our Prisons Are Making The Mental Health Crisis Worse

There are now ten times more individuals with serious mental illness in prisons and jails than there are in mental institutions, according to a new report yesterday from the Treatment Advocacy Center. This is a jarring statistic, reinforcing the wisdom that prisons and jails have become de facto asylums, with as many mentally ill individuals in prisons as there were in asylums decades ago.

But what does it tell us about our policy? That we should have more psychiatric beds, or less prison ones? Probably both, but only if we re-design our system to aspire toward treatment rather than isolation, according to Doris A. Fuller, one of the authors of the study.

The 10-to-1 ratio is in part attributable to the fact that mental hospitals have fallen out of favor over the past half century. But what it represents is the corresponding trend of incarceration falling into favor. In fact, there are now as many mentally ill individuals in prisons as there were in asylums decades ago. And these prisons are in many ways even less suited to treat these individuals than the asylums were, meaning mentally ill inmates leave the prisons significantly worse than they entered.

“Prior to the introduction of effective medication in the 1950s, conditions for patients in state mental hospitals were often abysmal. Exposés of these conditions provided a major impetus for the de-institutionalization of the patients and the closings of hospitals,” the report states. “However, by shifting the venue of these mentally ill individuals from the hospitals to prisons and jails, we have succeeded in replicating the abysmal conditions of the past but in a nonclinical setting whose fundamental purpose is not medical in nature.”

Here are some examples of these conditions from the survey:

In New York, a man with schizophrenia was in prison for 15 years, 13 years of which were spent in solitary confinement. In a Minnesota county jail, a man with schizophrenia blinded himself with a pencil while “standing naked in his cell, standing in his own feces, screaming gibberish.” In a Mississippi prison specially designed for mentally ill inmates, “rats climb over the prisoners’ beds, and some prisoners capture the rats, put them on makeshift leashes, and sell them as pets to other inmates.” President John Kennedy, as part of his proposal to close state psychiatric hospitals, promised that “the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability.” This unquestionably is not what he meant.

There are several stages at which the criminal justice system disadvantages the mentally ill. First, minor offenses often caused or exacerbated by mental illness are subject to jail time. These include substance abuse-related offenses, loitering, trespassing, and other non-violent minor offenses. Second, once individuals are arrested, not only are they sent to jail rather than diverted to treatment; they end up “spending more time in jail because they’re sick,” said Doris Fuller, one of the authors of the study.

“One of the sad things is you’ll see people who commit a minor offense, say trespassing,” said Fuller, who is the executive director of TRAC. “They’re in jail but not stable enough to arraign. So you’re holding them until they’re sane enough to enter a plea. And if they don’t get treatment, they can’t get sane enough to enter a plea.”

At both of these stages — before these individuals become chronic inmates — treatment for the mentally ill outside cell walls is most significant. While psychiatric hospitals were over-used and misused during their prime in the 1950s, Fuller nonetheless said part of the solution is to make available more public psychiatric beds for those in crisis. These mental institution beds are equivalent to the emergency room for those with serious mental disorders, she said, and right now there is “no capacity to handle emergencies.”

The United States now has 17,000 public psychiatric beds for mentally ill individuals in crisis who are not criminals, while about 3.3 percent of the population has schizophrenia or severe bipolar, Fuller said. “What other disease do 3.3 percent of the population have in which there are no hospital facilities?” Fuller said.

But mental health professionals are not aiming to return to the era where psychiatric beds were the default and treatment was like modern-day prison. Instead, they are aiming for more robust outpatient services, as part of a coordinated mental health system. The focus of TRAC’s report, which was authored by 7 authorities on mental health and criminal justice, is on those who refuse treatment because they don’t believe they have a disorder. In those instances, referring those who end up in the criminal justice system is particularly significant.

“One of the other recommendations in the study … is to mandate that correctional facilities release those inmates with a plan,” said Fuller. “A plan basically like a discharge plan that you get from a hospital. A plan for how they are going to get doctor care in the community. This is barely used at all and there was one study of inmates released from prison without follow-up treatment. They’re almost four times more likely to commit another violent crime compared to mentally ill inmates who leave prison or jail and get treatment. Why wouldn’t staying in treatment be part of their probation?”

For those who need to be in jails and prisons, the problems of solitary confinement and other means of “punishing” the mentally ill are dire. One recent South Carolina court ruling revealed how that state’s prison authorities routinely abused, neglected, and humiliated these inmates, allowing several to die after grave medical neglect and holding them naked — even bleeding — in restraint chairs for hours. While these practices would be cruel as applied to anyone, studies have found they have particularly long-lasting impacts on those who already suffer from mental illness.

“We closed the psychiatric hospital because we thought it was inhumane to house them in these hospitals. But now we seem to have accepted as a society that it is totally humane to house them in jails and prisons,” said Fuller. “Are people really aware that this is what we’re doing?”